trauma


A combination of nothing particularly bad happening overnight or during the day, and me getting in earlier, made the day pass a lot more smoothly.

Interns, junior residents, and chiefs, think about a service differently. Interns are focused on the set of patients assigned to them. They know they’re responsible for that group, but anything else is out of their comprehension, and indeed they’ll probably get shooed away if they spend too much time thinking about patients they haven’t been assigned. Junior residents feel responsible to keep an eye on the intern’s patients, but they also limit themselves to some extent, because they know that the chief feels ownership of the entire service, and they don’t want to violate the chief’s prerogatives by taking too much responsibility for the service as a whole.

The chief, on the other hand, knows that there is no one but him to be responsible for the entire affair. Yes, the attending is responsible, but he’ll manifest that by asking the chief about anything that comes up, and expecting a solid, coherent, well-researched answer. The chief has to keep an eye out for the details on every patient, no matter which resident they are “assigned” to. He has to know all the important lab and imaging results, and the treatment plan for everybody, because that’s what keeps the service alive. If he misses a patient, there’s no one else to catch it.

I’m cautiously trying to develop that attitude. I can’t do it much when a real chief is around, because they hate it when the junior residents supervise too much. But when there’s no chief, I’m the one who has to make sure nothing slips through the cracks: no one gets mislaid in the ER, no important lab results get neglected for half a day, consultants are called as appropriate, patients who are going to the OR are prepped for the OR, and inspected for damages upon their return. I’m gradually shaking the intern habit of tuning out when a patient I’m not “following” is being discussed.

I’m also developing an amazing appetite for reading the textbooks at night. I’d better know more about what I’m doing. Just taking people’s word that “this is what we usually do” is not enough.

Halfway through the morning: “Alice, what’s going on with this patient? Why don’t you know?” Alice mumbles something. “That’s no excuse. You’re filling the role of senior resident today. Take care of things.”

Uh, thanks. Thanks for mentioning the role change after I’m already in trouble. I knew I was the senior, I just didn’t realize how much the attendings count on the senior on an every day basis, which means how much they count on me, even when I’m not forewarned.

That was the beginning of the rest of the day. Back to as bad as life was in June, constantly behind, expectations on all hands – attendings, nurses, interns, medical students – that I’m not fulfilling. Patients that are not receiving the amount of care I want them to have. Jobs not getting done, because every time I pick one thing up, three other people call me about something else. And getting berated the whole time.

There’s something definitely broken inside my head. The more I get rebuked, the more I want to do better. Any rational person at this point would say, Who cares what the attendings think, their expectations are unreasonable and their comments are uncalled for, forget about them, I’ll do what I want, and let them deal with it. But no, all I can do is figure that, if they expect me to function as the chief, then I’ll come in earlier and plan to stay later, so I can do everything right. As frustrated as I am, I can’t stand not to beat this. I can be responsible for thirty+ patients, I can know everything about their labs and scans and current conditions, I can be in touch with a dozen different consulting teams whose residents understandably growl at me whenever I page them and change their answer whenever my attending asks; I can. Even if it means working fifteen hours a day all week. The chief does it, right? Why shouldn’t I?

Besides, that’s the only way life will get any better. The attendings sure won’t suddenly decide to leave me alone.

Another of my patients died, and all I could think was, “Good, I don’t have to do all the DNR paperwork, I only have to fill out the death certificate, call the coroner, and dictate a death summary.” I guess I got used to death pretty fast.

Well, we could see it coming all day. The attending talked with the family some, and then got swallowed up in a deluge of real traumas. Everyone else went off to those, and I was left as the person senior enough to handle the ICU, but junior enough not to be absolutely needed in the ER, a very disconcerting seniority level indeed. Here Alice, take care of all the crashing ICU patients while we handle the wild stuff in the ER.

I’m not good like the social workers are with grieving families. I watched closely the other day, the last time a patient died, and the family was dissolving in the hallway. I hate watching people cry; it’s horrible to be involved, but outside enough that you can’t quite join in. The social worker was really good. The main thing I took away was a much higher level of physical involvement than the medical personnel usually allow themselves. So tonight I tried that, and it seemed to go ok; and other than that I said all the comforting things I could think of.

I hate being comforting, under any circumstances. The things the patients and families want to hear from you are usually at varying odds with the truth or with reality. I’m getting better at it, but it still gives my truth-gauge quite a twinge to make all kinds of reassuring statements: things will be ok, everything will be fine, it’s better this way, there was no pain, he’s comfortable, it will be all right. . . The phrases that people expect from doctors, need to hear from the doctor in order to have peace with themselves. . . I don’t really believe most of it, but I have to say it. . . like the parts of the Orthodox liturgy asking for Mary’s intercession; I don’t believe it, but it’s too important (and beautiful) to not say. . . So I read my lines, and try to give a convincing impersonation of a reassuring doctor.

I was going to keep talking, but it was getting too incredibly morbid. I’m tired of the ICU, can we go on to September now?

Things are usually fairly quiet till 4 or 5pm; before that, you can get a couple of little old ladies falling down stairs, or old men falling over their canes (that’s actually what the trauma pager said). Depending on whether the neurosurgeons have a white cloud or a black cloud on call, they could get one or two operative subdural hematomas out of that list.

5pm, just when you’re wishing for dinner, is when the action starts. 39 year old female, MVC (motor vehicle crash). She was drunk, and everyone in the trauma bay wonders how she got that way at 5pm, and wouldn’t it be nice if we had the time to do that too (actually, I’m surprised how many of the staff voice this thought; you’d think we’d have learned by observation the dangers of drinking). She has a small post-traumatic subarachnoid hemorrhage, which is somehow much less lethal than the ruptured-aneurysm variety, so she gets a night in the ICU for observation. Next!

56 year old male, pedestrian vs. car. Depending on his luck, this could mean a variety of injuries. Tonight, a tib-fib fracture, a radius/ulna fracture, some facial lacs. He gets to spend the night, or maybe a couple nights, till ortho has time to fix his fractures. This time of year, they operate practically non-stop, and if you don’t have an open fracture, it may take a day or two to get to the top of the OR schedule.

91 year old female, MVC vs retaining wall. (Who let her drive? Amazing how many concerned family members show up once the damage is done.) Of course she’s taking coumadin; we’ll be lucky if she isn’t taking plavix too (notorious blood thinners; coumadin can be reversed, plavix can’t). Lucky for her, no intracranial hemorrhage, just an ankle fracture, with the incision of her knee replacement above it torn open, and a few nonsignificant vertebral fractures. Collar x12 weeks, OR in a few days with ortho. She can go to a floor, but it has to be a monitored floor, because of her atrial fibrillation, and we can’t tell whether she had some kind of cardiac event that caused her to black out or lose control of the car. That’s why cardiac enzymes are part of the laundry list of labs sent from the trauma bay.

Then, three in a rush: by helicopter, unhelmeted driver MCC (motorcycle crash), obtunded, open fractures; unhelmeted passenger MCC, intubated, closed fractures, distended abdomen; by ground, 89 year old man with a head bleed, from a nursing home via an outlying hospital. It’s the luck of the draw which one of them hits the door first. The old man has intracerebral contusions on the CT from the outside hospital, which we dutifully repeat: his mental status is deteriorating, he’ll be intubated by morning, and there’s nothing neurosurgery can do to help. Call the trauma ICU for a bed.

The motorcycle driver isn’t that obtunded once he arrives; drunk would be a more accurate term. Drunk enough to be quite cheerful, and not to understand what’s happened. He makes plenty of noise, though, when ortho shows up to reduce his fractures and splint them before taking him up to the OR.

His girlfriend is another story. She seems to have a head injury bad enough to have gotten intubated already, which makes the rest of the exam a little more difficult, since she can’t tell us what hurts. Neurosurgery is in the background, grumbling about her having gotten vecuronium for the intubation, and a couple hits of fentanyl for sedation/pain control on the helicopter ride over (because that obscures their exam, and besides the vital signs, there’s little more important about a trauma patient than getting a good neuro exam). Once they’ve finished giving the story, the chopper nurses can be heard muttering about the dangers of transporting a flailing patient in a confined space.

What few members of the trauma team haven’t split off with the other recent arrivals hurry through the protocol: pupils are equal, still reactive;  no blood in her ears, so it doesn’t look like a basilar skull fracture; lung sounds a bit diminished on one side, but it’s hard to tell in the commotion of the trauma bay; can’t be sure, so we’ll wait to put a chest tube till we see the chest xray (the xray technicians have a great knack for pushing themselves into the middle of the commotion and standing still until we notice and make way for them). Abdomen is distended, good peripheral pulses, maybe a bit weak – can we get a manual blood pressure please? – veins hard to stick, somebody put a femoral introducer in, give us some labs, hook up the rapid infuser; where’s the FAST? Someone pulls up the little ultrasound cart, designed to take a quick look at four spaces where there should be no free fluid; if you see a black line around the heart, or between the liver and kidney, or around the bladder, or between the spleen and kidney, you have hemopericardium or hemoperitoneum, and in an unstable patient, should go straight to the OR. She isn’t exactly unstable, her pressure’s staying at 100 with several liters of saline running, so we decide to take her to CT for a look at her head. CT shows various intraparenchymal contusions with tight ventricles from the swelling – neurosurgery states their desire to place a ventriculostomy as soon as she’s still in one place long enough – but the abdominal CT is the chief’s jackpot for the night: a shattered spleen, in four different pieces, with the dye from the iv contrast frankly extravasating around it. Call the OR, we have a trauma ex lap. Neurosurgery requests to be paged once she’s intubated, so they can do the ventric while we open the belly. . . Brief stop in the ER to arrange lines in order, dress a few gaping wounds, and let the OR open their instrument trays, and another piece of the team is off upstairs with her.

The pager is still going off. 58 year old male, fall, intoxicated, altered level of consciousness. 19 year old male, ATV accident, chest pain, shortness of breath. 87 year old female, fall at nursing home. 26 year old male, gunshot wound to the thigh. 28 year old male, gunshot wound to the chest. 20 year old male, stab wound to the abdomen. You never know what they really are. The 58 year old might arrive with such poor consciousness that he’s already been intubated. The ATV rider might have a pneumothorax, or nothing more than a bruised chest. The 87 year old female might have nothing wrong with her, or she might have a subdural, a C2 fracture, and a splenic laceration. The gunshot to the chest might arrive in traumatic arrest, or it might have grazed his side. It’s like a very bad Christmas nightmare – you never know what’s inside the package. And it isn’t even midnight yet; the real drunks will start showing up later.

This is getting better. I got to do another bronchoscopy today, and actually saw something useful (instead of just getting the scope jammed inside the tube and not being able to move; while the attending kept saying, “You see the carina? Go down the right side, ok, now go down the left side. . .” while I wasn’t actually moving at all, and then wanted to know why I wasn’t done already).

The rest of the residents want to know why it’s always my patients who need all the procedures. Somehow, I’ve managed to do almost all the procedures so far this month, without actually stealing anything from them. I wouldn’t mind if my patients would stop crashing, but I’m not controlling that. I need to make an effort not to pick up the sickest of the new patients every morning, so we can share the excitement.

At one point there were enough traumas coming in (as a general principle, men over 70 should not be allowed to climb ladders, and people over 90 should not be allowed to walk on stairs) that I was admitting by myself again. I got the sweetest little old lady, who very calmly coped with us running all around her in the trauma bay, and told me, “There’s nothing wrong with me, sweetheart. I know you need to check, but I’m really just fine. No, I never had any surgeries. I usually don’t come to the hospital, you see, until lately. No, nothing’s hurting me. I told you there’s really nothing wrong, you don’t have to worry.” There was something wrong (little old ladies over 70 always break something when they fall), but hopefully it won’t be too serious, especially since her first words, when I told her the bone was broken, were, “I’m not going to have surgery, ever, no matter what, so that settles it.”

The fun part was when her daughter came in to see her, and it turned out that I’d spent several nights, one night float month, dealing with this daughter’s post-operative complications. One night she’d have low urine output, another night an arrhythmia; then she got an ileus and was throwing up and I had to put in an NG tube; and so on and on, till I finally got off night float before she left the hospital. She was quite well now, and told her mother everything would be fine, she knew the doctor. It was sweet, but also a little daunting, that I’ve been in one hospital so long that I’m starting to treat families. I wasn’t expecting quite this much continuity in surgery residency.

I don’t know whether it’s good for my patients or bad for me, but today was the first time I had to make the decision to intubate a patient. (Other times, the decision had already been made.) It was actually pretty straightforward: RN: “Alice, the patient’s sats are in the 80s, and I can’t make them come up.” Alice: “I see you have him on a nonrebreather mask and have been suctioning him. Sir, can you open your eyes? Can you talk to me? No. Ok, the sats are dropping further, let’s start bagging, let’s call anesthesia.” Done. It’s usually a bad sign when you can intubate without paralytics or sedatives. Then we spent the rest of the day trying to figure out which came first, the chicken or the egg: the altered mental status or the respiratory failure.

Next time, if the aggressive chief is around, we might skip the “call anesthesia” part. At this hospital, anesthesia residents are always available (although available might mean 10-15 minutes away, not always good in a less controlled code than this one was), so the intubations are almost always done by them. But the equipment is there in the ICU, and there’s something to be said for knowing how to intubate when you have to. Of course, there’s never a good time to learn. Where I went to school, there were no anesthesia residents, and the surgery residents were responsible for intubating any time a code was called, or for trauma patients in the ER – so they learned pretty quickly.

Also for the first time I supervised another resident putting in a subclavian line. I’d tried to supervise before, but my tolerance level for teaching on awake patients is still pretty minimal. We both did better with the patient intubated and sedated.

I think I’m turning into “friendly reference material” for the interns, since they can be pretty sure I won’t mock them if they ask questions. I’m afraid I’m also behaving like a mother hen, trying to help some of the weaker interns who are getting picked on. I’m not sure I’m approaching the situation correctly, and I hope that I know enough myself that my advice doesn’t end up getting them in more trouble. I also wonder whether my kindness doesn’t undermine the high demands inherent in surgical residency; eventually, patients will die if you make the wrong choices, and getting a harsh response to a stupid answer is only preparation for that. But I figure there are enough men around here who will provide that aspect, it shouldn’t unbalance things too much if some of the women adopt a gentler approach.

Events of the day included:

Me deciding to address all the attending’s pet peeves by acting on them before he did. Result, the nurses were mad at me as well as him, and I don’t think I saved much time. It did make the attending happy, though.

Attempted bronchoscopy: Attending: “Sure, you can do it with me. Have you ever done any of these before?” Me: “Yes, definitely. (sotto voce Twice, to be precise.”) Attending: “This is how it’s done, bzzzbtttbzzz (words all blurred together). Ok, go.” So whatever I remembered from the previous two times disappeared, between the attending being not wanting to do it at all, and being in a hurry, and the patient actually having a problem.

For my commenters: Attending: “Anesthesia left the a-line hanging loose again. Suture it in right now.” Me: “Yes, let me find some suture. Um, I once heard a rumor that suturing radial a-lines promotes infection and thrombosis. (Although my literature search showed nothing of the sort.” The attending looked at me as though I had just sprouted an extra head. (Note to self, not to refer to blog commenters anymore unless accompanied by evidence.)

Taught three different people how to place post-pyloric feeding tubes – on the same patient, because every time we got one in, confirmed placement, and start feedings, he’d get it out by yet another method.

And spent all spare minutes trying to adjust the ventilator settings on the sickest patient in the unit, who has all kinds of unusual methods being tried on him, and none of them are working. Only two doctors in the unit really understand his respiratory status, and of course they’re not there all the time. I perhaps flatter myself in thinking that I understand a little of their methods, certainly more than the people who say, “I have no idea why he chose these settings, I don’t understand the rationale at all, let me tweak it a little.” So all day long the people who did have a clue would walk by and laugh bitterly at my blood gases, and inquire why it was taking me all day and I hadn’t done x/y/z obvious thing to correct the glaring abnormalities. Thanks for the help, folks.

I’ve spent so much time in the hospital lately that coming out into the sunlight feels like culture shock: there is light like this around commonly?

I’ve figured out (belatedly, perhaps) that the hard part of call is only between midnight and 5am. That’s when the circadian rhythm really demands to slow down and go to sleep. Before, and even after, is not that bad. In fact, looking at the sunlight now makes me feel fairly wide awake, although I know i’ve missed so much sleep lately that if I don’t catch up on at least a fraction of it today, the rest of the week will be ruined.

Part of it, too, is the discipline we started learning back in grade school math: I don’t want to finish these problems, to pay attention and work all the way through, but I will anyway. At a certain point in the night, I really do not want to be there at all. It would be so delightful to simply walk away; not even out of the hospital, just into the callroom, and decide to ignore pages for an hour or two, or even just to ignore the jobs that ought to be done even though no one will page about it (checking labs and imaging ordered earlier, walking around to check on the critical patients, filling out some of the mountains of paperwork that have to be done at night because if saved for daylight they’ll overwhelm the team’s resources). But I won’t; I’ll keep going regardless of what I’d like to be doing.

There’s a point in the middle of an endless stream of traumas, one or two every fifteen minutes, where every single person in the ER looks at the others and says, “Why am I here, and why am I doing this?” And no one has much of an answer, so someone says something flippant, and we keep going. Or a patient threatens to leave AMA, and we all shrug: Sure, do us a favor, the door is that way.

Then there was the time I decided to put my head down on the desk for five minutes, and when the nurse came to ask me about something, I jumped so hard she was more startled than I was. I think I have too much of a startle reflex. I’d been half-awake the whole time, knowing it was a matter of minutes before someone needed something from me, and I still leaped to my feet. I’m usually a very solid sleeper, but I’ve trained myself to never really sleep in the hospital. I’m too worried about the consequences (to a patient, or to my career) if I sleep through a page. So I’m always half listening, and waking up every now and then to check the pager and make sure I didn’t miss anything. Which makes me rather unsympathetic to the new medical students and interns who do occasionally sleep through their pagers. I can have slept 4 hours in the last 48, and still jump up the second my pager goes off.

Those are bad numbers. Maybe I’d better go to sleep now. . .

I forgot how much I hated, er, didn’t like, trauma. It’s pleasant to be back in a closed unit where the nurses recognize me, and most of them seem to like me (as in, they’re very happy to have me back around because I do scut the fastest, like reordering meds, and fixing orders that other people put in wrong, or coming quickly when they want someone to look at the patient).

On the other hand, as I said, I forgot how much I hate rounding all day. This weekend, fortunately for all who are interested in my sanity, the most annoying attendings are not rounding. The one who was, however, has certifiable ADD; so does the chief; and I come close, especially in their company. Neither of them can finish a sentence, let alone a train of thought, without jumping to something else, and then jumping back halfway through. The chief and I get along well, because I’m just scatterbrained enough to follow his jumps, and guilty of it enough myself that I can’t get as annoyed with him as other people do. (Incidentally, I don’t believe in ADD either; but it’s a convenient label that lets you all know what I mean.)

But rounds with the three of us was kind of crazy. I’d recite all the facts on a patient, the attending scribbling away and giving a very good impression of listening. Then he’d give some orders about the patient we’d just walked away from, run into the next room to check on something, come back, and ask me whether I’d mentioned a blood pressure or a fever on the patient, and what did the CT results show? So I would repeat what I had just told him. “Let me see the chest xray. Oh good.” Run back into the room to look at the pulse ox. Back out. “We need to start tube feeds. What’s the white count? Did we order a CT for the last guy? Has this person had a head CT recently? Is neurosurgery going to come see the guy down the hall?” And every time you start an answer, he moves on to the next one, then comes back, impatient because you haven’t answered the last several questions.

It works ok, because we’re all conscientious enough to make notes, and keep coming back to go over things until it all gets covered. But it does get a little wearing, and the nurses were left standing there with a dazed look, saying, “Were you talking about my patient at all, and if you were, did you decide to do anything important?”

Correction to the last post: I guess there was one attending in the group whom I didn’t totally antagonize. If we were playing a game of “pick one attending you’d like to be on the good side of,” I’d have chosen him, since he’s powerful, and has a very sharp tongue when he’s displeased. Actually, I don’t know how, I seem to have impressed him well enough that as I spent the morning stumbling through rounds, he remarked a couple of times: “I know Dr. Alice is a very good resident. In fact, she’s one of the best we’ve had all year. I don’t know what’s happened to her this morning, but I guess we can excuse her for one day.” Mmm, thanks; I suppose there’s a limit to how many days I can work straight, no time off, pushed to the limit, pulled in a dozen different directions for critically ill patients every ten minutes, without starting to crack a little bit. So I picked a good attending to stay friendly with.

In other ways, this day has to have been one of the worst of the year. More than one patient with seriously bad outcomes, which are maybe somehow someone’s fault. I can’t honestly tell whether it’s truly my fault, but I keep getting caught in this whirlpool: I should have done something different, I really should have; could I have changed this? was it physically possible for me to be in enough places to have caught this? I should have known; I should have, I should have. Some of the more senior residents saw me standing still, I guess looking as miserable as I felt, and made some remarks that I shouldn’t get too personally involved with the patients. I told them briefly what had happened, and they backed up. “Well, as bad as that, ok.”

All year, when I breezed through things, the seniors and chiefs have told me, “We’re paranoid, and after you have enough patients get hurt around you, you’ll be paranoid too.” The last month I think does it for me, and especially the last few days. Now I know why the best doctors here are obsessive about every single detail – because you never know which detail is going to come back to bite you, maybe to kill or maim your patient.

The best junior residents I’ve watched all year were the ones who came in early and stayed late, even when they were working night shift, or post-call, to double-check on things, and watch over patients till the oncoming team had thoroughly grasped the situation. Now I know what drives them, and I resolve to simply stop caring what time of day it is. I’ll mark my hours how I please, but I’ll stay, every single time, till I know all the details, till the next team knows all the details. Nothing outside of the hospital matters compared to making sure I’ve done the best possible for every person I’m responsible for. I am sick of seeing what can happen when things slip through signout; perhaps more precisely, I’m sick of worrying about whether something slipped.

On the other hand, as I contemplate being on call the Fourth of July (I was expecting that; given the small number of junior residents, and the surgical attitude of “throw them in the deep end and see if anyone figures out how to swim,” I knew I was going to be on call very early in the month), I realize that this month, as nightmarish as it’s been, has made me feel very comfortable with handling all kinds of calls about ICU patients, and semi-comfortable with the prospect of juggling admissions, consults, and disasters by myself. I guess there’s an element of familiarity about it too: I’ve been looking ahead to this kind of responsibility for a year, and I think I know better what’s expected of me (if not what I should expect) than I did heading into internship. (Now if various seniors would just stop making rueful remarks about me being a junior in three days. I can’t tell if they’re serious or not, or how concerned they are.)

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